| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
868 |
400 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
643 |
301 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
156 |
108 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
668 |
665 |
$16K |
| D1120 |
Prophylaxis - child |
563 |
560 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
794 |
790 |
$12K |
| D1110 |
Prophylaxis - adult |
320 |
317 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
231 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
108 |
45 |
$6K |
| D0274 |
Bitewings - four radiographic images |
187 |
185 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
359 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
126 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
292 |
$4K |
| D0272 |
Bitewings - two radiographic images |
203 |
202 |
$4K |
| D1351 |
Sealant - per tooth |
44 |
13 |
$1K |
| D0240 |
|
24 |
12 |
$364.56 |